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Michael Semyonov,1,* Ekaterina Fedorina,1,* Anna Shalman,1 Michael Dubilet,1 Yael Refaely,2 Leonid Ruderman,2 Dmitry Frank,1 Benjamin F Gruenbaum,3 Leonid Koyfman,1 Michael Friger,4 Alexander Zlotnik,1 Moti Klein,1 Evgeni Brotfain1 1Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel; 2Department of Cardiothoracic Surgery, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel; 3Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA; 4Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel*These authors contributed equally to this workCorrespondence: Evgeni BrotfainDepartment of Anesthesiology and Critical Care, Soroka Medical Center, Ben Gurion University of the Negev, Beer Sheva, 84101, IsraelTel +972 54-621-8106Email bem1975@gmail.comPurpose: Neuropathic, chronic pain is a common and severe complication following thoracic surgery, known as post-thoracotomy pain syndrome (PTPS). Here we evaluated the efficacy of an ultrasound-guided serratus anterior plane block (SAPB) on pain control compared to traditional pain management with intravenous opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) six months after thoracic surgery.Patients and Methods: In this retrospective observational study, we analyzed data from a questionnaire survey. We interviewed all patients who underwent elective video-assisted thoracoscopy surgery (VATS) at Soroka University Medical Center between December 2016 and January 2018. The responses of ninety-one patients were included.Results: Participants reported PTPS in both groups, 43% of patients in the SAPB group and 57% of patients in the standard group, which failed to reach significance. However, we demonstrated that the percentage of pain occurrence trended lower in the SAPB group. There was significantly less burning/stitching or shooting, shocking, pressure-like, and aching pain in SAPB patients compared to the standard protocol group. Patients in the SAPB group had significantly less pain located in the upper and lower posterior thorax anatomical regions compared to the standard protocol group. Moreover, we found a significant difference in occurrence of PTPS depending on the type of thoracic surgery. From both study groups, 69% of patients who underwent lobectomy reported pain, compared with 41.9% of those in the segmental (wedge resection) procedure, and 42.1% of patients in other procedures.Conclusion: While the present study did not demonstrate a statistically significant reduction of PTPS after SAPB concerning postoperative pain control, there was a trend of a decrease. We also found significance in the type of pain and location of pain after thoracic surgery between the two groups, as well as a significant difference between pain occurrence in types of thoracic surgeries from both groups.Keywords: chronic pain, post-thoracotomy pain syndrome, PTPS, regional anesthesia block, serratus anterior, thoracic surgery

Aviel Avraham Azulay,1,2 Yael Refaely,1,2 Leonid Ruderman,1,2 Lior Nesher,1,3 Michael Semionov1,4 1Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 2Department of Cardiothoracic Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 3Infectious Diseases Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; 4Division of Anesthesiology and Critical Care, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, IsraelCorrespondence: Aviel Avraham AzulayDepartment of Cardiothoracic Surgery, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, 151 Yitzhak Rager Blvd, Beer-Sheva, IsraelTel +972 8-6400962Fax +972 8-6400961Email aviel_azulay@hotmail.comAbstract: This case report describes a patient with an unusually large pulmonary hydatid cyst and discusses important management issues.Keywords: hydatid disease, lung infection, surgery complications, anesthesia, re-expansion pulmonary edema

Yael Refaely,1* Leonid Koyfman,2* Michael Friger,3 Leonid Ruderman,1 Mahmud Abu Saleh,1 Moti Klein,2 Evgeni Brotfain21Department of Cardiothoracic Surgery, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel; 2Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel; 3Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel *These authors contributed equally to this workIntroduction: Emergency department thoracotomy (EDT), also termed “resuscitative thoracotomy”, is indicated in some cases of life-threatening isolated thoracic injury, or as a part of CPR (cardiopulmonary resuscitation) in multiple trauma patients, or in thoracic trauma patients with massive bleeding (such as intra-abdominal exsanguination or injury to the great vessels). There is a lack of information in the literature concerning predictors of survival after EDT in patients with predominant or isolated thoracic trauma.Patients and methods: The study was retrospective and single-center. We collected clinical and laboratory data from all civil and military trauma patients admitted to our emergency department (ED) with predominant thoracic injuries who underwent EDT at Soroka Medical Center. A total of 31 patients were included in the study.Results: Of the patients in the study group, 58% presented with penetrating thoracic injuries and 42% presented with blunt thoracic injuries. 13 patients (42%) survived the EDT procedure. The following parameters predicted survival after EDT: signs of life and the presence of sinus rhythm on admission to the ED; heart rate at the end of the EDT procedure; short duration of EDT; and total positive balance (fluid and blood products) after EDT. Patients who sustained penetrating stab wound injuries had a better immediate post-operative survival rate after EDT than those who sustained penetrating gunshot wounds or predominant blunt chest trauma (30.8% vs 11.1%; p-0.034). Six patients (19%) survived until discharge from the hospital: 3 with penetrating injuries and 3 with blunt thoracic injuries.Conclusion: In patients undergoing EDT after thoracic injury we found that the clinical status on admission to the ED, the duration of the EDT procedure and the heart rate at the end of procedure were predictors of survival after EDT. We demonstrated a higher survival rate after EDT in patients with predominant penetrating thoracic trauma.Keywords: emergency department thoracotomy (EDT), blunt chest trauma, penetrating chest trauma

Michael Semyonov,1,* Ekaterina Fedorina,1,* Julia Grinshpun,2 Michael Dubilet,1 Yael Refaely,3 Leonid Ruderman,3 Leonid Koyfman,1 Michael Friger,2 Alexander Zlotnik,1 Moti Klein,1 Evgeni Brotfain1 1Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel; 2Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; 3Department of Cardiothoracic Surgery, Soroka Medical Center, Ben‑Gurion University of the Negev, Beer Sheva, Israel *These authors contributed equally to this work Background: Patients who undergo surgical procedures that impair the integrity of the chest wall frequently experience extremely severe postoperative pain. Opiates and weaker analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are not sufficiently effective in achieving control of severe pain and might cause respiratory and gastrointestinal complications. In the past decade, there has been an increased interest in the use of regional nerve blocks for post-thoracoscopy and post-thoracotomy analgesia. Methods: This is a prospective, randomized, double-blind and single-center study. We recruited 104 patients who underwent elective thoracoscopy. Prior to surgery, the participating patients were randomized into one of two study groups: Group 1- the “standard control group” that received standard postoperative pain control with intravenous opioids, NSAIDs and acetaminophen (paracetamol) and Group 2- the “block group” that was treated by ultrasound-guided serratus anterior plane (SAP) block (a single injection of 0.25% bupivacaine hydrochloride 2 mg/kg plus dexamethasone 8 mg) with standard postoperative pain control regimen. We compared the clinical, laboratory, and postoperative pain assessment data of both groups. Results: Patients in the SAP block Group 2 reported significantly lower levels of pain after thoracic surgery as assessed by their visual analog scale scores, as compared to the patients in the standard pain control Group 1 (P

Rationale: Interlobar fissure integrity has previously correlated with responsiveness to endobronchial lung volume reduction therapy in patients with advanced emphysema. Objective: This report summarises the effect of interlobar fissure integrity on responses to treatment with a novel endoscopic tissue sealant (AeriSeal emphysematous lung sealant (ELS)) that collapses hyperinflated lung. Methods: Fissure status, lung volumes, tissue density and disease heterogeneity were assessed radiographically in 28 patients (age 63.4±6.1 years, 20 men) with advanced upper lobe predominant emphysema (density=888.0±18.2 HU; upper lobe tissue density < -950 = 2.62±1.74). Post-treatment changes in lobar volume, pulmonary function, exercise capacity, symptoms and quality of life were compared in patients with complete fissures (CFs) and incomplete fissures (ICFs). Results: ELS therapy reduced lung volumes independent of interlobar fissure integrity. In patients with upper lobe emphysema and CFs, lobar volume reduction was 214±127 ml/treatment compared with 256±175 ml/treatment in those with ICFs (p=0.453). Reductions in gas trapping and improvements in spirometry, functional capacity and quality of life were similar in patients with CFs and ICFs. Stepwise multiple regression modelling confirmed that fissure integrity did not contribute to post-treatment changes in forced expiratory volume in 1 s, residual volume/total lung capacity ratio or lobar volume measured by CT analysis. Conclusions: Interlobar fissure integrity, an important determinant of responsiveness to endobronchial lung volume reduction therapy in prior studies, had minimal impact on physiological and functional responses to ELS therapy in patients with severe upper lobe predominant emphysema. Clinical Trial Registration Number: Registration numbers for trials contributing to datasets in this report: NCT00884962, NCT01051258 and NCT01181466. [ABSTRACT FROM AUTHOR]

Rationale: Biologic lung volume reduction (BioLVR) is a new endobronchial treatment for advanced emphysema that reduces lung volume through tissue remodeling. Objectives: Assess the safety and therapeutic dose of BioLVR hydrogel in upper lobe predominant emphysema. Methods: Open-labeled, multicenter phase 2 dose-ranging studies were performed with BioLVR hydrogel administered to eight subsegmental sites (four in each upper lobe) involving: (1) low-dose treatment (n = 28) with 10 ml per site (LD); and (2) high-dose treatment (n = 22) with 20 ml per site (HD). Safety was assessed by the incidence of serious medical complications. Efficacy was assessed by change from baseline in pulmonary function tests, dyspnea score, 6-minute walk distance, and health-related quality of life. Measurements and Main Results: After treatment there were no deaths and four serious treatment-related complications. A reduction in residual volume to TLC ratio at 12 weeks (primary efficacy outcome) was achieved with both LD (-6.4 +/- 9.3%; P = 0.002) and HD (-5.5 +/- 9.4%; P = 0.028) treatments. Improvements in pulmonary function in HD (6 mo: DeltaFEV(1) = +15.6%; P = 0.002; DeltaFVC = +9.1%; P = 0.034) were greater than in LD patients (6 mo: DeltaFEV(1) = +6.7%; P = 0.021; DeltaFVC = +5.1%; P = 0.139). LD- and HD-treated groups both demonstrated improved symptom scores and health-related quality of life. Conclusions: BioLVR improves physiology and functional outcomes up to 6 months with an acceptable safety profile in upper lobe predominant emphysema. Overall improvement was greater and responses more durable with 20 ml per site than 10 ml per site dosing. Clinical trial registered with www.clinicaltrials.gov (NCT 00435253 and NCT 00515164). [ABSTRACT FROM AUTHOR]

Background: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. Methods: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at Least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. Results: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. Conclusions: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults. [ABSTRACT FROM AUTHOR]

Purpose: In the pursuit of creating personalized and more effective treatment strategies for lung cancer patients, Patient-Derived Xenografts (PDXs) have been introduced as preclinical platforms that can recapitulate the specific patient's tumor in an in vivo model. We investigated how well PDX models can preserve the tumor's clinical and molecular characteristics across different generations., Methods: A Non-Small Cell Lung Cancer (NSCLC) PDX model was established in NSG-SGM3 mice and clinical and preclinical factors were assessed throughout subsequent passages. Our cohort consisted of 40 NSCLC patients, which were used to create 20 patient-specific PDX models in NSG-SGM3 mice. Histopathological staining and Whole Exome Sequencing (WES) analysis were preformed to understand tumor heterogeneity throughout serial passages., Results: The main factors that contributed to the growth of the engrafted PDX in mice were a higher grade or stage of disease, in contrast to the long duration of chemotherapy treatment, which was negatively correlated with PDX propagation. Successful PDX growth was also linked to poorer prognosis and overall survival, while growth pattern variability was affected by the tumor aggressiveness, primarily affecting the first passage. Pathology analysis showed preservation of the histological type and grade; however, WES analysis revealed genomic instability in advanced passages, leading to the inconsistencies in clinically relevant alterations between the PDXs and biopsies., Conclusions: Our study highlights the impact of multiple clinical and preclinical factors on the engraftment success, growth kinetics, and tumor stability of patient-specific NSCLC PDXs, and underscores the importance of considering these factors when guiding and evaluating prolonged personalized treatment studies for NSCLC patients in these models, as well as signaling the imperative for additional investigations to determine the full clinical potential of this technique., (© 2024. The Author(s).)

Objective: Teleoperated robot-assisted minimally-invasive surgery (RAMIS) offers many advantages over open surgery, but RAMIS training still requires optimization. Existing motor learning theories could improve RAMIS training. However, there is a gap between current knowledge based on simple movements and training approaches required for the more complicated work of RAMIS surgeons. Here, we studied how surgeons cope with time-dependent perturbations., Methods: We used the da Vinci Research Kit and investigated the effect of time-dependent force and motion perturbations on learning a circular pattern-cutting surgical task. Fifty-four participants were assigned to two experiments, with two groups for each: a control group trained without perturbations and an experimental group trained with 1Hz perturbations. In the first experiment, force perturbations alternatingly pushed participants' hands inwards and outwards in the radial direction. In the second experiment, the perturbation constituted a periodic up-and-down motion of the task platform., Results: Participants trained with perturbations learned how to overcome them and improve their performances during training without impairing them after the perturbations were removed. Moreover, training with motion perturbations provided participants with an advantage when encountering the same or other perturbations after training, compared to training without perturbations., Conclusion: Periodic perturbations can enhance RAMIS training without impeding the learning of the perturbed task., Significance: Our results demonstrate that using challenging training tasks that include perturbations can better prepare surgical trainees for the dynamic environment they will face with patients in the operating room.

Introduction: Empyema secondary to pneumonia is a common condition. A significant number of patients will require surgical intervention for drainage and decortication. The aim of this study was to identify predictive factors for surgical intervention. Materials and Methods: The medical records of patients who were diagnosed with empyema secondary to pneumonia between the years 2010 and 2019 in a university hospital were included in the study. Patients who underwent surgical intervention were defined as group A and nonoperative treatment as group B. Clinical and laboratory data were collected from medical records and patients' chest computerized tomography (CT) scans were reviewed. Results: A total of 194 patients were included in the study-86 patients were included in group A and 108 patients in group B. Several parameters on admission were found to have a statistically significant correlation with surgical intervention: younger age, higher systolic blood pressure, and elevated white blood count. Multivariant analysis showed that younger age was found to have a statistically significant correlation with operative intervention (adjusted odds ratio = 0.971, P  = .023). A statistically significant correlation between surgical intervention and survival (adjusted hazard ratio [HR] = 1.762, P  = .046) and an inverse correlation between age and survival (adjusted HR = 0.050, P  < .001) were found. Surgical intervention was associated with increased survival irrespective of age. A total of 42 CT scans were available for review. The mean density of the empyema fluid in group A was higher by 4.3 hounsfield units compared to group B ( P  < .067). Conclusions: Younger age was found to be associated with surgical intervention among patients suffering from empyema secondary to pneumonia. Surgical intervention was associated with increased long-term survival, irrespective of patients' age. Several radiologic characteristics were associated with the need for surgery in this study: empyema fluid density, pleural thickening, and fluid loculations. Additional prospective studies are required to ascertain these results.

During the past 74 years since its establishment, Israel has evolved into a modernized country with well-established and effective public health care system. Thoracic surgeons in Israel play a central role in the diagnosis and treatment of patients with diseases of the chest wall, diaphragm, mediastinum, airways, Lung, and esophagus as well are taking part in designated trauma teams. Between 2,500-3,000 cases are being performed in 16 designated thoracic surgical units and departments across the country annually, the majority of them being performed in a minimally invasive fashion. Lung cancer is the leading cause of cancer related mortality in Israel and the second most common cancer in Israel. All types of thoracic oncologic cases are being presented routinely during designated multi-disciplinary conferences and treatment plans are designed according to the most up to date international guidelines. Each surgeon undergoes at least 6 years of formal training, followed by certifying exams. Advanced training is usually obtained overseas in centers of excellence. Israeli thoracic surgeons are part of an international societies and are actively involved in academic research. Despite the advancement of the Israeli health care system, thoracic surgeons in Israel are still facing few challenges that are limiting the early diagnosis of thoracic surgical malignancies such as lack of established national lung cancer screening program in Israel although a pilot program is being tested during these days. Tasked with taking care of diseases of the chest, and in order to remain at the forefront of diagnosis and treatment similar to our colleagues across the globe, Thoracic surgeons in Israel are continuously seeking to learn and evolve in order to improve and provide better care to our patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-668/coif). The series “Thoracic Surgery Worldwide” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Objective: Robotic-assisted minimally invasive surgery (RAMIS) became a common practice in modern medicine and is widely studied. Surgical procedures require prolonged and complex movements; therefore, classifying surgical gestures could be helpful to characterize surgeon performance. The public release of the JIGSAWS dataset facilitates the development of classification algorithms; however, it is not known how algorithms trained on dry-lab data generalize to real surgical situations., Methods: We trained a Long Short-Term Memory (LSTM) network for the classification of dry lab and clinical-like data into gestures., Results: We show that a network that was trained on the JIGSAWS data does not generalize well to other dry-lab data and to clinical-like data. Using rotation augmentation improves performance on dry-lab tasks, but fails to improve the performance on clinical-like data. However, using the same network architecture, adding the six joint angles of the patient-side manipulators (PSMs) features, and training the network on the clinical-like data together lead to notable improvement in the classification of the clinical-like data., Discussion: Using the JIGSAWS dataset alone is insufficient for training a gesture classification network for clinical data. However, it can be very informative for determining the architecture of the network, and with training on a small sample of clinical data, can lead to acceptable classification performance., Significance: Developing efficient algorithms for gesture classification in clinical surgical data is expected to advance understanding of surgeon sensorimotor control in RAMIS, the automation of surgical skill evaluation, and the automation of surgery.

Epithelioid hemangioma (EH) and epithelioid hemangioendothelioma (EHE) are both rare vascular tumors. EH tumors are often benign while EHE tumors have moderate malignant potential. Here, we present three unique cases at Soroka Medical Center, two featuring EH of the bone and one presenting EHE of the mediastinum. Each case demonstrates distinct treatment challenges due to the rarity of both diseases and lack of established guidelines. We propose three treatment approaches including pazopanib for salvage therapy of EH of the bone and minimally invasive surgical resection which in these cases lead to complete symptom relief and tumor stabilization upheld over time with close follow-up., Competing Interests: All the authors have no conflicts of interest to declare., (Copyright © 2021 by S. Karger AG, Basel.)

Introduction: Rib fracture fixation is becoming more popular and widely accepted among trauma surgeons worldwide as the recommended treatment method for flail chest injury. Recent data demonstrate improved results when compared with non-operative treatment. Improved outcomes were reported regarding ICU stay, need for tracheostomy, length of hospital stay, ventilator-associated pneumonia (VAP), and even death. The objective of this study was to ascertain whether clinical respiratory para-meters are improved after rib fracture fixation procedure., Material and Methods: This is a prospective study using a retrospective cohort for control, which took place at the Soroka University Medical Centre, Israel. Inclusion criteria included all patients over 18 years of age with flail chest injury or multiple ribs fractures, who were admitted to the General Intensive Care Unit (GICU). Between October 2015 and December 2018, we identified 24 patients who had their rib fractures operatively fixed and compared them to 61 patients with flail chest and multiple rib fractures, who were admitted to our GICU between the years 2010 and 2015 and were treated non-opera-tively. In all the surgical cases operations were performed within 72 hours of arrival in accordance with our treatment algorithm. All fractures were fixed using specialised anatomic locking plates/nails. Demographic data were collected, and respiratory parameters before and after the surgery were recorded and analysed., Results: We compared patients who had had their rib fractures fixed with a cohort group of patients who had been treated non-operatively in the past. No demographic differences were found between the 2 groups, nor were there any differences in their clinical trauma scoring, mechanical ventilation days, length of ICU stay, VAP, and death rates. The respiratory parameters (paO2/FiO2 ratio and chest wall compliance) were significantly higher during the 3 ensuing days after surgery and continued to improve in Group 1 (rib fixation group), in comparison to group 2 (non-operative) patients (P = 0.007 and P < 0.0001, respectively). The peak inspiratory pressure and PEEP para-meters were significantly lower in group 1 in comparison to group 2 during the 3 days, in favour of the operated group, with significant improvement noted over the 3 days post-surgery (P = 0.007 and P = 0.02, respectively)., Conclusions: We suggest that surgical treatment of flail chest and multiple rib fractures has clinical benefit and improves respiratory parameters even in the presence of multiple trauma injuries.

A ground glass opacity (GGO) lung lesion may represent early stage adenocarcinoma, which has an excellent prognosis upon prompt surgical resection. However, GGO lesions have broad differential diagnoses, including both benign and malignant lesions. Our objective was to study telomere length and telomerase activity in patients with suspected lung cancer in which GGO was the predominant radiographic feature. Knowledge of telomere biology may help distinguish malignant from benign radiographic lesions and guide risk assessment of these lesions. Peripheral blood samples were taken from 22 patients with suspected adenocarcinoma with the GGO radiographic presentation. Multidisciplinary discussion confirmed the need for surgery in all cases. We used an age and gender-matched group without known lung disease as a control. Telomere length and aggregates were assessed by quantitative fluorescence in situ hybridization (QFISH) and quantitative PCR. Cell senescence was evaluated by senescence-associated heterochromatin foci. Subjects with GGO lesions had a higher percentage of lymphocytes with shorter telomeres (Q-FISH, P = 0.003). Furthermore, relative telomere length was also reduced among the GGO cases (qPCR, P < 0.05). Increased senescence was observed in the GGO group compared to controls (P < 0.001), with significant correlation between the senescence-associated heterochromatin foci and aggregate formation (r = -0.7 and r = -0.44 for cases and controls, respectively). In conclusion, patients with resectable early adenocarcinoma demonstrate abnormal telomere length and cell senescence in peripheral blood leukocytes compared to control subjects. Abnormal telomere biology in the peripheral blood may increase suspicion of early adenocarcinoma among patients with GGO lesions., (© 2019 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Introduction: In contrast to an emergency department of thoracotomy (EDT), an urgent thoracotomy (UT) is defined as a surgical thoracic intervention performed in the operating room within the first 48 hours of the patient's intensive care unit (ICU) stay. The factors affecting survival after UT are not fully understood. In this study, we retrospectively analyzed the clinical data and outcome of patients with blunt and penetrating chest injuries who underwent UT., Methods: All adult patients who had blunt or penetrating chest trauma and who underwent UT, were included in the study. All data were collected from the patients' hospital and ICU records. Forty-five patients with thoracic injuries who underwent UT during the first 48 hours of ICU stay were analyzed. Of these, 25 had penetrating chest injuries, and 20 had blunt thoracic injuries. Of the penetrating injuries, 16 were stab wounds, and 9 were gunshot wounds., Results: Overall ICU mortality was 29% ( n  = 13) and was significantly higher in the blunt chest trauma group than in the penetrating trauma group (45% vs 16%; p  = 0.04). Lung parenchyma injuries (lacerations and contusions) were the most common intraoperative findings in both groups. The following independent predictors of in-hospital mortality were found: an Injury Severity Score (ISS) of >40; an Acute Physiology and Chronic Evaluation II (APACHE II) score of >30; prolonged duration of UT; low body temperature on admission to the ED; abnormal arterial blood lactate, bicarbonate, and pH at the end of UT; and use of vasopressors during the first 24 hours of ICU stay., Conclusion: Mortality after UT was higher in patients with blunt chest trauma. The UT should be performed in both penetrating and blunt chest trauma as quickly as possible and should be limited to damage control. It also emerges that acidosis and hypothermia in chest trauma patients need to be treated extremely aggressively before, during, and after UT., Competing Interests: The authors declare no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Adenocarcinoma (AC) and squamous cell carcinoma (SCC), sub-types of non-small cell lung cancer (NSCLC), both present unique features at the genome, epigenome, transcriptome and proteome levels, as well as shared clinical and histopathological characteristics, but differ in terms of treatment. To ensure proper treatment, one must be able to distinguish between these sub-types. Here, we identify novel biomarker proteins in NSCLC, allowing for distinguishing between the AC and SCC sub-types. Proteomics analysis distinguished between healthy and tumor tissues, with the expression level of 1,494 proteins being altered, 378 of which showed a ≥|100|-fold change. Enrichment of proteins related to protein synthesis and degradation, and of proteins associated with mitochondria, metabolism, and apoptosis, was found. Network analysis defined groups of proteins, such as those associated with cell metabolic processes or with fatty acid/lipid metabolism and transport. Several biomarkers that enable for distinguishing between AC and SCC were identified here for the first time, and together with previous reports confirmed here, led us to propose a list of proteins differentially expressed in SCC and AC. Some of these biomarkers are clear signatures for AC or SCC and four of them are secreted proteins. The presence of the mitochondrial protein SMAC/Diablo in the nucleus was found to be a signature for SCC. Precise diagnosis of AC and SCC is essential for selecting appropriate treatment and thus, increasing patient life expectancy. Finally, the search for drugs that target some of these biomarkers may lead to new treatments for lung cancer., Competing Interests: CONFLICTS OF INTEREST The authors declare no competing financial interests.

Small cell lung cancer (SCLC) is characterized by a relatively high rate of autoimmune phenomena. Paraneoplastic limbic encephalitis (PLE) is an autoimmune syndrome in which a non-neural tumor containing an antigen normally present in the nervous system precipitates an antibody attack on neural tissues. Patients with PLE usually present with rapidly progressive short-term memory deficits, confusion or even dementia. Palmar fasciitis and polyarthritis syndrome (PFPAS) is another autoimmune syndrome characterized by rheumatologic manifestations, especially involving the palms of the hands. We report a case of a 59-year old woman who presented with worsening neurological symptoms of two-week duration, and later coma. The combined clinical, serological, and imaging studies suggested a diagnosis of PLE. A chest computed tomographic scan showed a 1.2 cm-diameter mass in the upper lobe of the left lung that was surgically removed and showed SCLC. Following surgery, neurological symptoms rapidly improved, allowing the patient to receive adjuvant chemotherapy. While in remission for both SCLC and PLE, the patient developed pain, soft-tissue swelling, and stiffness in both palms, suggesting the diagnosis of PFPAS. Five months following the diagnosis of palmar fasciitis, SCLC relapsed with mediastinal and cervical lymphadenopathy. This case report underlines the continuous interaction of SCLC with the immune system, expressed by coexistence of two rare paraneoplastic diseases, PLE, and PFPAS, in a patient with SCLC. While symptoms related to PLE preceded the initial diagnosis of SCLC, other symptoms related to PFPAS preceded relapse.

Propionibacterium acnes is an anaerobic, Gram-positive bacterium which causes numerous types of infections. Isolated Propionibacterium acnes deep neck infections are very rare. We present an interesting case of deep neck infection complicated by descending mediastinitis of isolated Propionibacterium acnes infection.

Alterations in cellular metabolism and bioenergetics are vital for cancer cell growth and motility. Here, the role of the mitochondrial protein voltage-dependent anion channel (VDAC1), a master gatekeeper regulating the flux of metabolites and ions between mitochondria and the cytoplasm, in regulating the growth of several cancer cell lines was investigated by silencing VDAC1 expression using small interfering RNA (siRNA). A single siRNA specific to the human VDAC1 sequence at nanomolar concentrations led to some 90% decrease in VDAC1 levels in the lung A549 and H358, prostate PC-3, colon HCT116, glioblastoma U87, liver HepG2, and pancreas Panc-1 cancer cell lines. VDAC1 silencing persisted 144 hours post-transfection and resulted in profound inhibition of cell growth in cancer but not in noncancerous cells, with up to 90% inhibition being observed over 5 days that was prolonged by a second transfection. Cells expressing low VDAC1 levels showed decreased mitochondrial membrane potential and adenoside triphosphate (ATP) levels, suggesting limited metabolite exchange between mitochondria and cytosol. Moreover, cells silenced for VDAC1 expression showed decreased migration, even in the presence of the wound healing accelerator basic fibroblast growth factor (bFGF). VDAC1-siRNA inhibited cancer cell growth in a Matrigel-based assay in host nude mice. Finally, in a xenograft lung cancer mouse model, chemically modified VDAC1-siRNA not only inhibited tumor growth but also resulted in tumor regression. This study thus shows that VDAC1 silencing by means of RNA interference (RNAi) dramatically inhibits cancer cell growth and tumor development by disabling the abnormal metabolic behavior of cancer cells, potentially paving the way for a more effective pipeline of anticancer drugs.

Endoscopic lung volume-reduction therapy for emphysema has been associated with therapeutic responses smaller in magnitude and less durable than surgical volume reduction (LVRS). Bronchoscopic emphysematous lung sealant (ELS) therapy has been shown to produce improvements in pulmonary function similar to surgery at 1 year. This case series summarizes safety and efficacy data of all patients from the initial ELS study out to 2 years. Between 1 and 2 years, there were three all-cause adverse events requiring hospitalization. One patient went on to successful lung transplant. Improvements relative to baseline in spirometry (change in FEV1: + 14.3 ± 33.1%; change in FVC: + 5.8 ± 23.2%) and diffusing capacity (change in diffusing capacity of the lung for carbon monoxide: + 10.6 ± 20.6%) were observed at 2 years. An exponential model fit to FEV₁ data at 6, 12, 18, and 24 months predicted improvements from a baseline of > 5% out to 4.1 years, similar to what has been reported following surgery. This report confirms long-term safety and efficacy following ELS therapy in advanced emphysema. Studies in a larger cohort are needed to define the role of ELS therapy in the treatment algorithm of patients with this condition.

Objective: Our objective was to evaluate whether resection and heated pleural chemoperfusion (HPCP) is an effective treatment for de novo stage IVa thymoma (DNT) and thymic carcinoma (TC) and for thymoma with pleural relapse (TPR)., Methods: A retrospective study was conducted of patients undergoing resection and HPCP in 1 center. HPCP with cisplatinum ± doxorubicin (adriamycin) was performed for 60 minutes using a standard roller pump and a modified heat exchanger to a maximal intrapleural temperature of 43°C. Follow-up included at least 1 annual computed tomographic scan until death or March 2012., Results: Thirty-five patients, 17 DNT, 14 TPR, and 4 TC, completed 42 intended treatments and were followed up for 4 to 202 months (median, 62 months). Seven patients had repeated HPCP at an interval of 2 to 12 years. There was no systemic toxicity. Ninety-day mortality was 2.5%. Major and minor morbidity occurred in 12% each. Five-, 10-, and 15-year overall survivals for DNT, TPR, and TC were 81%, 73%, 58% (DNT), 67%, 56%, 28% (TPR), and 0%, 0%, 0% (TC). Five- and 10-year progression-free survival was 61%, 43% for DNT and 48%, 18% for TPR. Presently, 11 of 17 DNT patients are alive (6, no evidence of disease), and 8 of 14 TPR are alive (6, no evidence of disease). Median survival for thymoma was 157 months. Overall survival was unrelated to any preoperative or intraoperative variable. Progression-free survival was improved in R0 compared with R1-2 resection (P < .001). Local control achieved in 21 (57%) of 37 procedures in thymoma patients was related only to completeness of resection (P = .015)., Conclusions: (1) Lung-sparing resection and HPCP is feasible and safe. (2) In thymoma with pleural spread it offers excellent survival despite moderate pleural control. (3) Preliminary results with stage IVa TC are disappointing., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: A clinical study was performed to assess the safety and efficacy of bilateral AeriSeal Emphysematous Lung Sealant System (ELS) treatment in patients with advanced emphysema out to 1 year., Methods: Twenty patients received treatment at four subsegments, two in each upper lobe. Tenhad upper lobe disease, and 10 had homogeneous disease. Treatments were administered under moderate sedation. Efficacy was assessed at 3, 6, and 12 months., Results: Procedure times were short (15.2 ± 9.6 min), and hospital length of stay averaged 1.1 days. The study was successful in reaching its primary end point of a reduction at 3 months in upper lobe lung volume assessed by quantitative CT scan analysis ( - 895 ± 484 mL, P < .001). Treatment was associated with improvements in spirometry ( Δ FEV 1 at 6 months = 31.2% ± 36.6%, 12 months = 25.0% ± 33.4%), gas trapping ( Δ residual volume/total lung capacity at 6 months = 2 7.2% 12.7%, 12 months = - 10.9% 14.0%), diffusing capacity of lung for carbonmonoxide (6 months = 12.7% ± 16.4%, 12 months = 12.3% ± 21.1%), symptom scores ( Δ Medical Research Council dyspnea score at 6 months = median 0, range - 2 to 1, 12 months = median - 1, range - 3 to 0), and health-related quality of life ( Δ St. George Respiratory Questionnaire at 6 months = 8.0 ± 17.2 U, 12 months = 7.0 ± 15.8 U). There was one serious procedural complication and seven all-cause significant respiratory adverse events over 17 patient-years of follow-up., Conclusions: Bilateral ELS treatment administered under conscious sedation in patients with advanced emphysema is associated with short procedure time and length of hospital stay and produces physiologic and functional improvement out to 1 year.

This report summarises phase 2 trial results of biologic lung volume reduction (BioLVR) for treatment of advanced homogeneous emphysema. BioLVR therapy was administered bronchoscopically to 25 patients with homogeneous emphysema in an open-labelled study. Eight patients received low dose (LD) treatment with 10 mL per site at eight subsegments; 17 received high dose (HD) treatment with 20 mL per site at eight subsegments. Safety was assessed in terms of medical complications during 6-month follow-up. Efficacy was assessed in terms of change from baseline in gas trapping, spirometry, diffusing capacity, exercise capacity, dyspnoea and health-related quality of life. There were no deaths or serious medical complications during the study. A statistically significant reduction in gas trapping was observed at 3-month follow-up among HD patients, but not LD patients. At 6 months, changes from baseline in forced expiratory volume in 1 s (-8.0+/-13.93% versus +13.8+/-20.26%), forced vital capacity (-3.9+/-9.41% versus +9.0+/-13.01%), residual volume/total lung capacity ratio (-1.4+/-13.82% versus -5.4+/-12.14%), dyspnoea scores (-0.4+/-1.27 versus -0.8+/-0.73 units) and St George's Respiratory Questionnaire total domain scores (-4.9+/-8.3 U versus -12.2+/-12.38 units) were better with HD than with LD therapy. BioLVR therapy with 20 mL per site at eight subsegmental sites may be a safe and effective therapy in patients with advanced homogeneous emphysema.

Background: One third of foreign bodies retained in the gastrointestinal tract are present in the esophagus. Their management depends on the anatomic location, shape and size of the foreign body, and duration of impaction., Methods: Between 1971 and 2001, 32 patients with foreign bodies in the esophagus were admitted to our service in the Wolfson Medical Center. Their charts were reviewed for preoperative diagnosis, kind and location of foreign body, length of retention, management of patients, complications, and length of hospitalization., Results: One patient was admitted with perforation of the esophagus. Thirty of the foreign bodies have been extracted at rigid esophagoscopy and two at thoracotomy. There was one complication (tear of esophageal mucosa) and one death., Conclusions: The presence of a foreign body in the esophagus is a challenging problem. Perforations may result in death. Impaction mandates immediate extraction. Our experience indicates that the use of a rigid esophagoscope is safe and reliable. Based on this experience and that of other authors, we recommend the use of the rigid endoscope as the instrument of choice for extracting foreign bodies from the esophagus. Surgeons in training should be taught rigid esophagoscopy.

Objective: In a previous study, we have shown that the sequence of vessel interruption (SVI) during lobectomy has no impact on tumor recurrence. The aim of the present study was to determine whether SVI has an impact on the amount of blood retained in the resected lobe., Patients and Methods: A non-randomized prospective study including 30 patients undergoing lobectomy for neoplasms. Group A-1'st had all lobar arteries ligated before interruption of the lobar vein and group V-1'st had a reverse sequence. Generous exclusion criteria were used, so as to include only patients with straightforward lobectomy, attempting to isolate SVI as the only factor that could affect blood loss. Lobar weight was recorded immediately after lobectomy. All ligatures and staplers were removed; blood drained from the lobe, collected and measured, and thereafter the lobe was weighed again., Results: Sixteen patients entered group A-1'st and 14 group V-1'st. The groups were similar in age, sex, body surface, histology, prior therapy, stage, FEV1%, length of operation, and number of segments resected. The amount of blood drained from the lobe was 31.4+/-13 and 34.2+/-14.8ml in group A-1'st and V-1'st, respectively. The lobar weights before and after blood drainage were 177.6+/-56.9, 141.7+/-49.1g and 201.5+/-74.2, 161.6+/-69.7g, respectively. The amount of blood divided to the lobar weight was 0.178+/-0.052 in group A-1'st and 0.177+/-0.099 in group V-1'st. All of these figures did not differ statistically. No patient required blood transfusion during or after surgery., Conclusions: In straightforward lobectomy the amount of blood retained in the resected lobe is small. This amount is not affected by the sequence of hilar vessel interruption.

Background: With recent advances in neoadjuvant therapy in esophageal cancer, pretreatment lymph node staging has become increasingly important in stratifying patients to appropriate treatment regimens and for prognostication. Immunohistochemical analysis (IHC) using epithelial markers has been shown to identify micrometastases in histologically negative lymph nodes. We performed this study to evaluate if IHC analysis in thoracoscopic/laparoscopic (Ts/Ls) pretreatment staging lymph nodes can reveal additional diagnostic information to routine histopathology., Methods: Specimens of 106 patients with esophageal cancer who had pretreatment Ts/Ls staging were retrospectively studied. Lymph node biopsies were obtained for IHC staining using cytokeratin (CK) of AE1/AE3. IHC staining for p53, an apoptosis protein associated with poor prognosis in esophageal cancer, was also performed., Results: 331 Ts/Ls staging lymph node biopsies were collected from 106 patients. A total of 15.4% (51/331) of the lymph nodes or 34.9% (37/106) of patients were found to have metastatic deposits by routine histology. All the histologically positive lymph nodes were CK positive. Among the remaining 280 histologically negative lymph nodes, 11(3.9%) were found to have micrometastasis by CK staining. Three patients (4.3%, 3/69) were upstaged from N0 to N1. They died of early recurrences after treatment. A total of 67.6% (25/37) of the patients with histologically positive lymph node were p53 positive. No histologically negative lymph node was found to be p53 positive in this series., Conclusions: Immunohistochemical analysis for CK can detect micrometastatic involvement of lymph nodes that are missed on routine pathologic examination, and, therefore, can improve lymph node staging. Its clinical significance in esophageal cancer warrants further study.

Objectives: This study was undertaken to determine the incidence and outcome of major bleeding complicating deep sternal infection after cardiac surgery, to identify predisposing factors and means of prevention, and to clarify management options., Methods: This was a retrospective study of 10,863 consecutive patients, of whom 213 (2.18%) acquired deep sternal infection. With 43 additional referrals, the total number of patients with deep sternal infection was 280. Deep sternal infection was managed by a two-stage scheme. Major bleeding was considered to be bleeding that occurred during or after operation for deep sternal infection from the heart, great vessels, or grafts, or bleeding requiring urgent exploration., Results: Fifteen patients (5.36%) had major bleeding. The incidences of deep sternal infection and bleeding were highest among patients undergoing coronary artery bypass grafting. Thirteen patients had underlying diseases (type 2 diabetes in 9 cases). Deep sternal infection was diagnosed a median of 15 days after reoperation. Bleeding originated from the right ventricle in 9 patients. In 4 patients bleeding was iatrogenic during surgery for wire removal (n = 2) or reconstruction (n = 2). In 11 it occurred 15 minutes to 15 days (median 2 days) after wire removal, as a result of shearing forces in 7 cases and of infection only in 4 cases. Three patients died immediately. The other 12 were operated on, 6 with complete cardiopulmonary bypass, 2 with femoral cannulation, and 4 without cardiopulmonary bypass. The immediate mortality was 26.7%; the overall mortality was 53.3%. The median length of hospitalization of surviving patients was 38 days., Conclusions: The probability of development of major bleeding in patients with deep sternal infection was unrelated to the primary operation. The mortality associated with this complication was high. Meticulous technique during wire removal may decrease the risk of major bleeding. The impacts of cardiopulmonary bypass and of the technique and timing of sternal reconstruction remain undetermined.

Background: Lung hernia is uncommon and methods of management vary. During the past 17 years, we have seen 8 patients with this condition., Methods: Between 1984 and 2000, 8 patients with lung hernias were seen on our service. Three hernias were caused by a thoracic operation, one was due to chronic cough, and in four, the hernia was congenital, with delayed presentation., Results: Three patients had minimal symptoms and were not operated on. Closure of chest wall in the other patients was accomplished by suture approximation of ribs in 4 patients and by polypropylene mesh in 1 patient. There were no recurrences, and these patients remain asymptomatic., Conclusions: Intercostal hernias are usually symptomatic and should be treated by operative closure. In supraclavicular hernias, the symptoms are usually minimal and complications are unlikely. These hernias can be left untreated, but the patients should be followed.

Esophageal cancer is undergoing a major shift in its epidemiology. Its incidence is dramatically growing and it more commonly affects younger and healthier patients. Based on the published data, there is no strong evidence to recommend routine preoperative chemotherapy for the treatment of surgically resectable esophageal carcinoma. It might be that a large-scale randomized study-which will be published in the near future-will shed some different light on this subject. The role of preoperative CRT remains undetermined. To settle this issue, larger, clinical, controlled trials are needed. Improvement in the preoperative regimen and use of new drugs should be evaluated. Concomitant CRT should be considered for potential benefit in survival and local control in patients who have localized disease and are candidates for radical non-surgical treatment. Patients with pCR following neoadjuvant therapy have a consistent, substantial survival benefit. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Pretreatment staging will be even more important in the future for adjusting treatment to individual patient. Video-assisted thoracoscopy and laparoscopy have been found to be the most accurate lymph node staging techniques.

Background: Malignant neoplasms involving the pleura have a poor prognosis. In some cases the main symptoms and the cause of death are due to local spread, whereas metastases, if at all, develop late. The preferred treatment of these tumors is not clear., Goals: To evaluate whether regional therapy that includes resection, local chemotherapy and hyperthermia is feasible, safe and effective for tumors with pleural spread., Material & Methods: Forty-three patients undergoing surgery and hyperthermic pleural perfusion were studied retrospectively. The majority had mesothelioma, or thymic malignancies with pleural spread. Twenty-five patients received previous treatment. The extent of resection was dictated by tumor type and patients condition. Perfusion was performed with a roller pump and heat exchanger plus cisplatinum in a dose of 60-200 mg., Results: Intrapleural temperature exceeded 40 degrees C in all patients. There were no hemodynamic, or respiratory problems related to perfusion. There was neither intraoperative mortality nor hematologic, renal or systemic toxicity. Three patients died (7% mortality) and 14 had complications. The overall 1, 2, 3, and 5-year survival rates ware 78%, 72%, 50% and 36% respectively. The best survival was for thymoma patients--70% after 3 and 5 years, and the worst for metastatic tumors--31% 3-year survival. Among 39 patients followed-up for more than 1 year (24 alive, 15 dead), 28 (72%) were free of ipsilateral pleuro-pulmonary recurrence., Conclusions: Surgery and hyperthermic pleural perfusion is feasible and relatively safe. This method offers a good chance of complete midterm local eradication of neoplasms with pleural spread. A survival benefit over other modalities is suggested in patients with thymoma. Other drugs, alone or in combinations, should be studied.

We report a case of chronic empyema and bronchopleural fistula after lobectomy for tuberculosis. The patient had undergone four different surgical procedures to correct his bronchopleural fistula during an interval of seven years. Finally, he had a successful closure of the fistula using the transsternal transpericardial approach.

Background: Video-assisted thoracoscopic surgery has become routine worldwide. On the basis of accumulating experience and technologic improvements, more complex operations can be performed. Until recently, thoracoscopic lobectomy has not been performed in Israel., Goals: To describe the initial experience with thoracoscopic lobectomy in Sheba Medical Center, and discuss the advantages, disadvantages and indications for its use., Material & Methods: From June 2000 to January 2001, five patients (3 male, 2 female) 22-72 year-old underwent thoracoscopic lobectomy. Four had malignant neoplasms (3 lung primary) and one a benign process. Preparations for surgery, anesthesia and monitoring were standard as for open lobectomy. Surgery was done through 3 ports and a 5-7 cm auxiliary thoracotomy. The majority of the operation was performed with staplers. In patients with lung tumors the regional lymph nodes were sampled. Pulmonary function tests were evaluated prior to surgery and in the immediate postoperative period., Results: Lobectomy was completed in all patients according to preoperative planning without conversion to open thoracotomy. Operative time was 120-160 minutes. Blood transfusion was not required in any patient during or after the lobectomy. There was no operative mortality and only two minor complications in one patient. Narcotic requirement did not exceed 40 mg of morphine in any patient. Pulmonary function tests revealed a smaller than expected decrease compared to open thoracotomy. The cosmetic results were excellent., Conclusions: Thoracoscopic lobectomy is feasible in Israel too. It is an acceptable alternative for patients needing this operation. Thoracoscopic lobectomy causes less surgical trauma, better functional result and expectance for lowered mortality and morbidity. Its main disadvantage is its high cost.

Background: A marked worldwide increase in prevalence of pulmonary tuberculosis occurred during the past 15 years. The reasons for this change include the worldwide epidemic of AIDS, poverty and unprecedented migration of people., Methods: During the past 12 years, we operated on 57 patients with pulmonary tuberculosis or its sequelae. In 42 patients the disease was active at the time of operation., Results: Two patients died of operative complications; one, of unrelated causes. There were three major non-fatal complications. In 49 patients tuberculosis was eradicated; five patients still have active disease and remain under drug therapy., Conclusions: High level of clinical awareness is the most important factor in disclosure and early treatment of pulmonary tuberculosis. Indications for operation are strengthened by alcoholism, drug abuse, poverty and other social factors. BCG vaccination of tuberculin-negative children should be considered as a preventive measure.